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Rail Transportation Safety Investigation Report R17w0267 RAIL TRANSPORTATION SAFETY INVESTIGATION REPORT R17W0267 EMPLOYEE FATALITY Canadian National Railway Company Remote control locomotive system Extra yard assignment Y1XS-01 Melville, Saskatchewan 22 December 2017 II | TRANSPORTATION SAFETY BOARD OF CANADA ABOUT THIS INVESTIGATION REPORT This report is the result of an investigation into a class 2 occurrence. For more information, see the Policy on Occurrence Classification at www.tsb.gc.ca The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. TERMS OF USE Use in legal, disciplinary or other proceedings The Canadian Transportation Accident Investigation and Safety Board Act states the following: • 7(3) No finding of the Board shall be construed as assigning fault or determining civil or criminal liability. • 7(4) The findings of the Board are not binding on the parties to any legal, disciplinary or other proceedings. Therefore, the TSB’s investigations and the resulting reports are not created for use in the context of legal, disciplinary or other proceedings. Notify the TSB in writing if this report is being used or might be used in such proceedings. Non-commercial reproduction Unless otherwise specified, you may reproduce this investigation report in whole or in part for non-commercial purposes, and in any format, without charge or further permission, provided you do the following: • Exercise due diligence in ensuring the accuracy of the materials reproduced. • Indicate the complete title of the materials reproduced and name the Transportation Safety Board of Canada as the author. • Indicate that the reproduction is a copy of the version available at [URL where original document is available]. Commercial reproduction Unless otherwise specified, you may not reproduce this investigation report, in whole or in part, for the purposes of commercial redistribution without prior written permission from the TSB. Materials under the copyright of another party Some of the content in this investigation report (notably images on which a source other than the TSB is named) is subject to the copyright of another party and is protected under the Copyright Act and international agreements. For information concerning copyright ownership and restrictions, please contact the TSB. Citation Transportation Safety Board of Canada, Rail Transportation Safety Investigation Report R17W0267 (released 10 June 2020). Transportation Safety Board of Canada 200 Promenade du Portage, 4th floor Gatineau QC K1A 1K8 819-994-3741; 1-800-387-3557 www.tsb.gc.ca [email protected] © Her Majesty the Queen in Right of Canada, as represented by the Transportation Safety Board of Canada, 2020 Rail transportation safety investigation report R17W0267 Cat. No. TU3-11/17-0267E-PDF ISBN: 978-0-660-35028-8 This report is available on the website of the Transportation Safety Board of Canada at www.tsb.gc.ca Le présent rapport est également disponible en français. RAIL TRANSPORTATION SAFETY INVESTIGATION REPORT R17W0267 | III Table of contents 1.0 Factual information ................................................................................................. 1 1.1 The accident ................................................................................................................................................. 3 1.2 Recorded information............................................................................................................................... 7 1.3 Hand brake application ............................................................................................................................ 7 1.4 Post-accident examination of car CN 302412 ................................................................................ 7 1.5 Accident re-enactment by the Canadian National Railway Company .................................. 8 1.6 On-site re-enactment by the TSB ......................................................................................................10 1.7 Hand-brake force testing of CN 302412 .........................................................................................11 1.7.1 Brake-shoe force testing .......................................................................................................14 1.7.2 Stopping distance calculations ...........................................................................................16 1.8 Regulatory requirements for hand brake positioning ...............................................................16 1.8.1 Transport Canada Railway Freight Car Inspection & Safety Rules .........................17 1.8.2 U.S. Federal Railroad Administration Code of Federal Regulations .....................17 1.8.3 Association of American Railroads Manual of Standards and Recommended Practices .......................................................................................................................................17 1.9 Safety appliances on railway cars.......................................................................................................18 1.10 Freight car inspection and maintenance .........................................................................................18 1.11 Canadian National Railway Company’s ballast car fleet inspections ...................................20 1.12 Crew information ......................................................................................................................................21 1.12.1 Foreman .......................................................................................................................................22 1.12.2 Helper ...........................................................................................................................................23 1.13 Kicking cars .................................................................................................................................................23 1.14 Requirements to conduct job briefings ...........................................................................................24 1.15 Previous uncontrolled movements at Melville Yard ...................................................................25 1.16 Remote control locomotive system ..................................................................................................26 1.17 Federal Railroad Administration report on the safety of remote control locomotive operations ...................................................................................................................................................26 1.18 Training and qualification of railway operating employees ....................................................27 1.18.1 Railway Employee Qualification Standards Regulations ............................................28 1.19 TSB Railway Investigation Report R16T0111 and Recommendation R18-02 ...................30 1.19.1 Transport Canada’s latest response to TSB Recommendation R18-02 (December 2019) ......................................................................................................................30 1.19.2 Board reassessment of Transport Canada’s response to TSB Recommendation R18-02 (March 2020) .........................................................................31 1.20 Guideline for Remote Control Locomotive Operation ..............................................................31 1.21 Railway Safety Management System Regulations, 2015 ..........................................................32 1.21.1 Risk management ....................................................................................................................33 1.21.2 Reporting contraventions, safety hazards, and close calls ......................................34 1.21.3 Managing knowledge.............................................................................................................37 1.22 Crew resource management ................................................................................................................39 1.22.1 VIA Rail Canada Inc. locomotive cab awareness training.........................................40 IV | TRANSPORTATION SAFETY BOARD OF CANADA 1.22.2 Canadian National Railway Company’s assessment of communication and coordination during conductor training .........................................................................40 1.23 Safety culture .............................................................................................................................................41 1.24 Safety culture at Canadian National Railway Company ............................................................42 1.24.1 Partners in Prevention ............................................................................................................42 1.25 Other TSB investigations involving training or experience while switching using remote control locomotive systems .................................................................................................43 1.26 TSB occurrence statistics involving unplanned/uncontrolled movements ........................43 1.27 Previous recommendation and safety concern involving uncontrolled movements ....47 1.28 TSB Watchlist ..............................................................................................................................................47 1.29 TSB laboratory reports ...........................................................................................................................48
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